Meadow Park Health & Specialty Care Center

F-F883.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 36 385222 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385222 B. Wing 01/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Helens Post Acute 75 Shore Drive Saint Helens, OR 97051

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38140

Residents Affected - Many Based on interview and record review it was determined the facility failed to ensure effective systems were in place to identify problems, and take action to improve and monitor its performance for 1 of 1 facility reviewed for quality assessment and assurance. This failure placed residents at risk for worsening care. Findings include:

On 1/21/25 at 2:15 PM the facility's undated 2024 Quality Assurance and Performance Improvement (QAPI) Plan for [NAME] Care (Meadow Park Care facility) included oversight of Administration, Clinical Care Services, Nutrition Services, Pharmacy Services, Quality of Life and Engagement, Maintenance Services, Housekeeping, and Training And Orientation. The plan included use of a QAPI Committee, Analytics, Core Processes, and Medical Oversight for purposes of Performance Improvement Projects, Systematic Analysis, Communication, QAPI Self-Assessment, as well as Feedback and Data Monitoring.

A review of the facility's Quality Assessment and Assurance (QAA) 2024 records revealed no evidence the facility enacted procedures related to problem identification, analysis, performance improvement, and monitoring.

On 1/21/25 at 2:32 PM Staff 2 (DNS) and Staff 3 (Regional Director of Clinical Operations) acknowledged the lack of evidence of an effective QAA program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 385222 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385222 B. Wing 01/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Helens Post Acute 75 Shore Drive Saint Helens, OR 97051

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or 35855 potential for actual harm Based on interview and record review it was determined the facility failed to ensure vaccines were offered for Residents Affected - Some 2 of 5 sampled residents (#s 8 and 301) reviewed for immunizations. This placed residents at risk for respiratory infections. Findings include:

A review of the facility's Influenza Vaccine Policy Statement revised in 2019 indicated all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the risks and benefits of vaccines to residents or their legal representatives.

1. Resident 8 was admitted in 7/2014 with diagnoses including traumatic brain injury and contractures of the left and right ankles.

A Pneumococcal, COVID-19 and Annual Influenza Vaccine Information and Request form indicated on 9/25/23 Resident 8's representative consented to request influenza vaccine annually.

No additional documentation was found in Resident 8's clinical record annual influenza vaccine was offered or received in 2024.

In interviews on 1/14/25 at 11:56 AM with Staff 2 (DNS) and 1/17/25 at 8:26 AM with Staff 1 (Administrator) Staff 2 and Staff 3 (Regional Director of Clinical Operations), Staff 2 stated he did not find recent consents for Resident 8, annual consents should be completed at a resident's care conference and it was his responsibility to have them completed yearly.

2. Resident 301 was admitted to the facility 12/2024 with diagnoses including chronic obstructive pulmonary disease (lung condition caused by damage to the airways which limits airflow and oxygen exchange)

An undated typed document received from the facility indicated Resident 301 did not have any current vaccine consents.

A review of Resident 301's immunization records revealed she/he received her/his last influenza vaccine on 10/3/23.

No additional documentation was found in Resident 301's clinical record the annual influenza vaccine was offered or received in 2024.

In interviews on 1/14/25 at 11:56 AM with Staff 2 (DNS) and 1/17/25 at 8:26 AM with Staff 1 (Administrator) Staff 2 and Staff 3 (Regional Director of Clinical Operations), Staff 2 stated he did not find recent consents for Resident 301. Staff 2 stated it is expected of staff to obtain vaccine consents on admission and the facility had difficulty with agency staff not completing them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 385222 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385222 B. Wing 01/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Helens Post Acute 75 Shore Drive Saint Helens, OR 97051

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm 35855

Residents Affected - Some Based on interview and record review it was determined the facility failed to ensure residents received risk and benefit of the COVID-19 vaccine information for 2 of 5 sampled residents (#s 8, and 301) reviewed for immunizations. This placed residents at risk for lack of information regarding vaccines. Findings include:

A review of the facility policy COVID-19 Policy and Procedure revised 12/2022 revealed all residents would be offered COVID-19 vaccines to aid in preventing COVID-19 and COVID like illness. Prior to, or upon admission, residents would be assessed for eligibility to receive the COVID-19 vaccine series, and when indicated, would be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident was already vaccinated. Assessments of the COVID-19 vaccination status would be conducted within five working days of the resident's admission if not conducted prior to admission. Residents should receive the risks and benefits and have the right to refuse the vaccination. If refused, staff would reapproach the resident or representative annually to offer the opportunity to accept or refuse the vaccine.

1. Resident 8 was admitted to the facility in 7/2014 with diagnoses including traumatic brain injury and contractures of the left and right ankles.

A Pneumococcal, COVID-19 and Annual Influenza Vaccine Information and Request form indicated on 9/25/23 Resident 8's representative refused the COVID-19 vaccination.

No additional documentation was found in Resident 8's clinical record the COVID-19 risks and benefits were offered or received in 2024.

In interviews on 1/14/25 at 11:56 AM with Staff 2 (DNS) and 1/17/25 at 8:26 AM with Staff 1 (Administrator) Staff 2 and Staff 3 (Regional Director of Clinical Operations), Staff 2 stated he did not find recent consents for Resident 8, annual consents should be completed at a resident's care conference and it was his responsibility to have them completed yearly.

2. Resident 301 was admitted to the facility 12/2024 with diagnoses including chronic obstructive pulmonary disease (lung condition caused by damage to the airways which limits airflow and oxygen exchange)

An undated typed document received from the facility indicated Resident 301 did not have any current vaccine consents.

A review of Resident 301's immunization records revealed she received her last COVID-19 booster on 12/20/22.

No additional documentation was found in Resident 301's clinical record the COVID-19 vaccination or risk and benefits were offered or received in 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 385222 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385222 B. Wing 01/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Helens Post Acute 75 Shore Drive Saint Helens, OR 97051

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 In interviews on 1/14/25 at 11:56 AM with Staff 2 (DNS) and 1/17/25 at 8:26 AM with Staff 1 (Administrator) Staff 2 and Staff 3 (Regional Director of Clinical Operations), Staff 2 stated he did not find recent consents Level of Harm - Minimal harm or for Resident 301. Staff 2 stated it is expected of staff to obtain vaccine consents on admission and the facility potential for actual harm had difficulty with agency staff not completing them.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 385222 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385222 B. Wing 01/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Saint Helens Post Acute 75 Shore Drive Saint Helens, OR 97051

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 38140

Residents Affected - Some Based on observation and interview it was determined the facility failed to ensure a functional and comfortable environment for 1 of 3 shower rooms reviewed for environment. This placed residents at risk for

an uncomfortable bathing experience. Findings include:

On 1/12/25 at 2:31 PM a resident stated the ambient air in the shower room near resident room one was cold when she/he bathed and the heater in there could not be used.

On 1/15/25 at 1:42 PM the State surveyor stood in the shower room between rooms one and two for about 10 minutes. The surveyors' fingertips became cold. A DO NOT turn heater on! fire hazard!! handwritten sign was observed posted in the shower room.

On 1/17/25 at 8:03 AM Staff 1 (Executive Director) was aware of the lack of a heat source in the shower room. Staff 1 confirmed the shower room heater between rooms one and two was an issue and needed to be replaced.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 385222